A Double Doubt: Neurotic Self and Agency in an Era of Shifting Ideology in Cuba
Concetta Russo
PhD Anthropologist
University of Milan ““Bicocca””
Email: [email protected]
Abstract: The clashing of Cuba and the capitalist world economy has heralded a new beginning in Cuba’’s revolutionary historiography.
This paper analyzes the psychotherapy as a way to reconceptualise subjectivity in this era of shifting ideology.My research has been
carried out in a Mental Health Community centre in La Habana (Cuba). Patients of this kind of Service are referred to as ““neurotics””,
people who, even though without a severe mental disorder, need psychological support because in a difficult moment of their lives. In a
situation where the patient is disoriented about his/her perception of the "state of things", psychiatrists and psychologists may become
the patient’’s guide.Nevertheless, as the results of my ethnographic research suggest, psychiatrists and psychologists don’’t use their
role to shape the psychiatric care into a form of governmentality. Instead, they use the therapy, and the ironic speech sometimes
included in it, also to highlight the social contradictions that bring citizens to a neurotic behaviour.
Keywords: Cuba, ideology, psychotherapy, neurotic-self, citizenship, and irony
1. Introduction
In the decades of the 1980s, also known as the most ambitious phase of the National Health System (I refer here to
Castro’’ s famous speech where he talks for the first time about Cuba as a world medical power), the Ministerio de salud
publica (MINSAP) initiated a proposal to train family physicians to participate in an innovative family medicine program.
The new program, which called for a family physician-and-nurse team to live and work in the communities they served,
was to become the cornerstone of the revolutionary vision of accessible community medicine. For this reason, Castro
declared the physicians who participated in this program the ““symbol of the Revolutions”” (Castro 1986).
The government created a model of health care that was informed by the revolutionaries’’ vision of a new social order,
which in turn would help create not only a ““non-sick person”” but also a ““healthy man””. This healthy man was described by
Hiram Castro-Lopez, one of the most important Cuban psychiatrists, as a «happy and functional citizen who cooperates
with the society he or she lives within» (Castro-Lopez 1980). This model of healthy person shows the important link
between the construction of National Health System and the revolutionary model of citizenship. During 1980s, while
Basaglia’’s movement as well as anti-psychiatry ones bestirred Europe, the Cuban government re-thought the mental
health care system. They rejected psychoanalytic patterns, because they are considered unsuitable to the socialist
model, and tried to create a ““Cuban”” psychotherapy model based on philosophical elements coming from the Soviet
psychology theory integrated with therapeutic practices of the systemic psychotherapy.
In order to provide health care services to their citizens, they created the Mental Health Community Service (Centro de
Salud Mental Comunitario), advocating against the adoption of a model of mental care based on private practice of
psychotherapy and rejecting the use of DSM (Diagnostic and Statistical Manual of mental disorders) considered a symbol
of North American hegemony in the global politics of knowledge.
My ethnographical experience was carried out in the biggest Mental Health Community Centre in Havana, during
eleven months, from October 2007 to July 2010. I was investigating how the political and economic model influences
both mental illness and the recommended mental health treatment. I suggest that –– even if the politics of cure service are
fixed- the care practices are dynamic and informed by the way psychiatrists imagine their own role in the Cuban society.
Another important issue of this article is the use of irony during the psychotherapy session; by the way, to show the
importance of it, it is necessary to give a description of the psychiatric system.
2. About psychotherapy in Havana
The Mental Health Community Service is part of primary health care, along with the family-physician, and it is supposed
to be the family doctor who suggests a person to go into psychotherapy. As Averasturi wrote: «when people with
emotional or behavioural problems come to the physician, after overall evaluation, the physician decides upon
counselling or deeper psychotherapy if needed» (Averasturi 1980). Anyway, as I could observe, the people’’s behaviours
are often totally different. They often don’’t choose the conventional way, i.e. speak with the physician about their personal
problem, and then, if he suggests that, go to Mental Health Community Service of their own Municipio (burgh). They
prefer to speak, for example, with a friend or a neighbour in order to ask for advice and then go to the psychiatrist that
cures a person they know. It’’s interesting to point out this behaviour, because it suggests that people talk about having
psychotherapy not only in the physician’’s surgery.
Patients of this kind of Service are referred to as ““neurotics””, people without a severe mental disorder that, in a difficult
moment of their lives, need a psychological support. As Basaglia argues, to talk about ““neurotics patients”” is very difficult,
even for an expert, to determine where the boundary between ““a problem”” and ““a disorder”” is, between sadness and
depression, or between ““regular fear”” and ““panic”” (Basaglia 1967; Lakoff 2005). Cuban psychiatry tries to resolve this
dispute with the concept of ““aptitude”” [in Spanish aptitud].
When a person arrives in the Mental Health Community Service, he or she undergoes an interview with a team of
therapists that work in the Service, formed by a psychiatrist, a psychologist, a social worker, a pedagogue, a
physiotherapist. (Indeed, the emphasis on traditional psychiatric practice has been replaced by a wider context that
represents a multidisciplinary approach.) Their role is to determine the kind of help the person needs. Usually the person
tells the history of problem, speaks about his/her personal life, family problems or job related issues. Then the psychiatrist
asks the person if he/she is determined to change ““aptitude”” bearing the problems, and if the person responds
affirmatively the psychiatrist suggests him/her to become a Daily Hospital patient.
The patient doesn’’t receive a diagnosis, but may continue with medication if he or she is considered too depressed or
anxious to begin psychotherapy. When I say ““not receiving a diagnosis””, I stress the fact that even if the psychiatrist
writes about the patient in his ““historia clinica”” (case history), speaks about the symptoms and the pharmaceutical
treatment, he doesn’’t give the patient an ““illness identity””. The patient is not ““ depressed””, he or she is not identified as
having a General Anxiety Disorder, but he or she is just ““a patient”” with a story, with some problems and with some
symptoms. They are ““patients”” and not ““clients”” because there is no charge for the provision of psychotherapy. Indeed,
psychotherapy practice as well as the entire Cuban medical system post-revolución is free of charge (Averasturi, 1980).
I think it is important to point out this lack of diagnosis, because the experience of psychiatric disorder interacts
dynamically with the way the experts recognize and name it (Lakoff, 2005). This absence of diagnosis in this context can
be linked with the absence of pharmaceutical industry hegemony in the Cuban Health System.
The English sociologist Vieda Skultans in his research about Psychiatric transformations in Latvia argued that the
sudden appearance of new psychiatric categories in Latvia, after the collapse of the Soviet bloc, has been aided by the
arrival of Western pharmaceutical companies with their persuasive literature conference, and by the World Health
Organization (WHO) funded translation of the International Classification of Disease and Related Health Disorder (ICD)
manual into Latvian in 1997 (Skultans, 2007).
In Cuba all the drugs are produced and commercialized by the State, and the Cuban Government doesn’’t need to
create a target in order to commercialize the marketing of drugs. Then, they don’’t need to adopt a ““logic of specificity””
(Rose and Novas, 2005) in mental health care, where any disorder has a specific name and then a specific treatment. In
this manner the medication is not linked with an illness, but just with the symptoms. This fact changes the perception of
cure: drugs can alleviate discomfort, can mask the symptoms, but they cannot cure.
Moreover, this lack of logic of specificity changes the psychotherapy treatment, too. Indeed, all the Daily Hospital
patients participate in the same activities. That is, when they become ““patients””, they attend the Mental Health
Community Service daily for a period between three or five months, from 8.00 a.m. to 4.00 p.m. During the treatment
period they receive group psychotherapy, act role-playing, have some cultural trips, and participate in different kinds of
activities, always as a group. The patients’’ group is normally of about twenty, men and women, with high school level. In
practice, there are no basic theoretical antagonisms between psychology and psychiatry in Cuba, because of this reason
they work together in day hospital with neurotic patients (Averasturi, 1980).
The psychotherapy is always group psychotherapy because, in the Cuban model, the group represents the society,
and the role of the therapist is to try to take care of society and not simply a single person.
During one session the psychiatrist says to the patients:
It is not possible to cure the human being as a single person without binds, the human being is a
system, with binds, with family, that lives in society…… for this reason our therapy is ““of group”” and not
only ““in group”” (15th July 2010)
This brief idea about the human being points out the link between the Cuban pattern of therapy, and the systemic therapy
of Palo Alto, but it is interesting to note that, even though the reference is clear, in the hand book of Cuban
Psychotherapy, written by Hiram Castro in 1980s, we cannot find any reference to systemic therapy or other North
American patterns. The local Knowledge Product (Young, 1997) about psychotherapy is shown as free from capitalism,
liberalism, and any symbols of cultural North American hegemony. Nevertheless, in the daily-practice of care it is
contaminated by different patterns, especially from Soviet Psychology and Systemic therapy.
Moreover, this idea that it is impossible to cure a human being separate from the society he or she lives in, underlines
why Cuban psychiatry rejects psychoanalysis today. During a conference in the University of Habana, one of the most
popular Cuban psychologists said:
The psychotherapeutic daily practice is moved on the citizens’’ needs. I mean, what really happens when you
interview a patient is that the Cuban people have to bear a hard life, and sometimes they can’’t find a solution
to their own problems. I can’’t treat with the psychoanalysis model a woman who is sad because she can’’t
have a home where she can live with her child. (Manuel Calviño, 2nd December 2009)
The planning of the Cuban mental health community program is based on the idea of the Government’’s responsibility
about the citizens’’ welfare, and even more on the idea that the welfare must depend on the relationship between the
person and his/her social environment, like Marxism points out. For this reason, psychiatrists and psychologists usually
visit their patients at home, or at their working-place, in order to observe the patients’’ home-environment and deeply
understand their problems. Another argument against psychoanalysis, is that in psychoanalysis the provision is
considered part of the treatment, and in Cuba health services are absolutely free because, as I wrote, health is
considered a citizen’’s right. On the other hand, during a debate between a group of Cuban psychiatrists and some
French psychoanalysts, doctor Ida (a Cuban childhood psychiatrist) made an important point when she said:
We should consider the difference between the ““first world”” psychotherapy and the ““third world”” one. We
operate in this world, which is hard and full of contradictions. So we have to analyse the core issues of our job:
there is a difference between interpreting and intervening on society. (Ida Inufio, 7th may 2008)
When doctor Ida said that there is a huge difference between ““interpreting”” and ““intervening on society””, she seems to
stress the dichotomy between psychoanalysis seen as theory of interpretation, and the Cuban mental health program
seen as social and politic intervention. Such a deep dichotomy that it seems impossible to keep them together. In this
kind of view, if a psychoanalyst treats just some clients, a Cuban psychotherapist should handle the daily problems with
his/her patients.
In order to analyze the meaning of ““intervening on society””, I would introduce another frame from my ethnography.
One day in the first interview with the team, a patient explains his pain because his family left the country and he spent
the last two years alone asking the Government to let him get out of the country1. And, when I asked the doctor about his
impression of this case, he replied:
They have to let him get out! He isn’’t depressed, he is just sad like everyone in this condition would be! We
can just try to help him to live his sadness until the day of his departure. (19th October 2009)
During the discussion of this case, the psychiatrist who was leading the session invited the therapeutic staff ““not to
consider a patient always as a patient””, it means not to consider their professional duty just in the boundaries of mental
health setting.
Without an illness identity and the need to find a diagnosis, the boundary between the cure process and the taking
care of people became thin. As one of the most popular Cuban psychologists wrote, often the problem that brings a
person to look for a psychological support belongs to his/her daily life, the economic condition of the country, the housing
problem (Calviño 2011). It is interesting to point out that both ethnographical frames suggest that the way the
psychologists and psychiatrists imagine their own social role is based on an awareness -shared by both psychiatrists and
patients- to live a ““vida dificil”” (hard life) that goes beyond mental health problems.
The Government didn’’t let him get out because he is a doctor. In Cuba a doctor who desires to leave the country, even for a while, has
to ask for the permission of the Ministry of Public Health, who rarely allows the request.
A Cuban psychiatrist or psychologist does not need to justify his intervention on the patient’’s behalf with a diagnosis.
They consider their responsibility to help the patient attain happiness and that is the main justification. Calviño spoke
fervently on this topic, stating: ““This is our duty: helping the people to be happy, what about science?”” (Calviño, 2nd
December 2009)
The aim of Cuban psychotherapy is to point out the aptitude of the patient with a difficult life and interpersonal
experiences, and then try to change this in order to improve the personal skills of the patient. Aptitude in this context
refers to how everyone faces everyday life, problems, and relationships; and considers the aptitude that produces pain,
panic, anxiety or depression (more than normally), incorrect. These feelings are considered symptoms of a ““neurotic
aptitude”” that could be cured with psychotherapy and other activities that point out the ““wrong part of a way of acting””. For
this reason, the Cuban model is called ““Modificación de actitudes”” [Modification of aptitudes].
3. The therapeutic use of irony
During the psychotherapy that I could observe during my fieldwork, people were sitting in circle and the therapists (the
same staff team noted earlier) were sitting with them, but the psychiatrist led the session. He started with silence, waiting
for a patient who needed to talk. Then, when a patient started talking, the psychiatrist or another member of the team
began asking questions and created links between the patients’’ stories, tried to explain the pattern of acting, the patients’’
““aptitudes””. The psychiatrist could use a different way of speech, in order to show the aptitudes to the patient, he was
usually provocative, trying to elevate the anxiety level of the moment to induce patients not just to ““speak about”” their own
problems but also to express their feelings and emotions. Any patient could talk about the other group’’s members’’
stories, give opinions, or try to compare his problem to the others’’.
In my experience the psychiatrist often compared his own problems with the patient’’s ones. He tried to put himself on
the same moral level as the patients’’; indeed, he spoke about himself not as an ““expert”” but more as a man who had
received psychotherapy and now, with his background, could give it.
Besides, the psychiatrist often said to the patients that they were ““patients””, but not ““sick persons””. He pointed out this
difference between a ““sick person”” and a ““daily hospital patient”” using the word ““citizen””. Also, during the psychotherapy
he often said: ““you are not sick persons, you are just citizens with problems!””
This way of calling the patients ““citizens”” brings me to the conclusions of this article, the analysis of the link between
politics and psychotherapy. As I wrote, psychotherapists (psychiatrists and psychologists) imagine their social role
likewise ““helping people to live better””. The object of analyzing the political speech that we could find in psychotherapy
brings me to analyse the use of irony during the psychotherapeutic encounter.
Paul Antze was the first to investigate irony in the psychotherapeutic encounter from an anthropological perspective;
he suggested we could find two different kinds of ironic speech. He called the first one ““rhetorical irony”” (or ““Socratic
irony””), it is the way in which the therapist shows the patient that he/she uses his/her symptoms to obtain what he/she
desires. The other one is ““dramatic irony””, he called so the interpretative strategy that lets the therapist reverse the
patient’’s logic of acting, in order to show him the real motivations of his acts (Antze, 2004).
Both kinds of irony are related with individual agency, and for this reason I thought they were a useful category of
analysis to speak about Cuban psychotherapy. In fact, the individual agency is one of the hot issues of psychotherapy,
even more in the case of Cuban psychotherapy, which takes care of patients’’ ““aptitude”” facing daily problems.
In Cuban psychotherapy we could find these two forms of irony, but a third one too: the ironic speech showed the
paradox of agency in this society of shifting ideology, but also improved the patients’’ critical attitude towards society. I will
show what I mean with two fieldwork frames.
During a session, on a day at the end of March 2009, Abel (a patient who was about thirty years old) was complaining
about the fact that he lived with his girlfriend but she didn’’t give him the home key. The psychiatrist, who led the session,
said to him: ““and so, now you know it is not your home! I don’’t understand why you are so sad, or surprised. Do you know
what? In Cuba nobody is the owner of his home!”” (In Cuba all the buildings are State propriety, nobody can, in a legal
way, sell his home, or buy a home2)
Another day, during a session, a patient, Maria, a nurse who was about fifty years old, said that she was ““submitted””,
and the psychiatrist asked her: ““Are you submitted? It is not a big deal! All the people that work for Salud Publica (Public
Indeed, in February 2012, Raul Castro opened the door to the home sale. By the way, when this fieldwork was carried on the home
sale was still illegal.
Health System) are submitted!””
First of all, while the patient was looking for some relief for his/her frustration, the therapist didn’’t give it to them, and
that is the use of ““dramatic irony””. The agency of the individual, which could be represented in the case of Abel by getting
the key of his girlfriend’’s apartment, is paradoxically overturned by ironic speech. In fact, if the patient got the key, he
wouldn’’t be the owner in any case, because, paradoxically, as the therapist told him, nobody would be. In the same way,
the psychiatrist didn’’t tell Maria that she shouldn’’t show her job frustration, indeed he stressed the fact it’’s impossible not
to be frustrated in this kind of job. This ironic turnaround of logic gets the effect of raising the patient’’s anxiety, but, on the
other hand, it puts the patient’’s suffering into a social perspective.
In fact, in both frames the therapist uses irony to reverse the patient’’s discomfort in citizen’’s hardships. In this way he
points out the problems of citizens and remarks upon the difference between ““problem”” and ““disorder””. Indeed, the
therapist uses irony in order to break the ““set apart”” (Turner, 1977) and to bring the political dimension into the
therapeutic setting, to make also the citizenship an object of care. The use of irony highlights the fact that society is not
considered as a normalizing agent, but rather that the common citizen’’s condition is hard to be lived by everybody.
4. Conclusion
Thinking over the bond between subjectivity and health politics, basing on Foucault’’s thesis, many authors have argued
that the Welfare State is also an instrument to make up the people. It means that a person, to have the right to be cured,
has to be compliant not only with the doctor but with the entire system that treats him/her (Foucault, 1977; Hacking, 20042005; Ong, 2005). Moreover, as sociologist Nikolas Rose argued, there is a close relationship between the historicity of
the self and the historicity of psychology and psychiatry, because the shaping of these disciplines is informed by the way
a particular kind of society (or historical era) conceptualizes the human being (Rose 2005)
The psychiatrist who led the Mental Health Community centre where I carried on my fieldwork spoke about the Cuban
psychotherapeutic model as a learning process. As a matter of fact, the Cuban psychotherapist should teach his/her
patients how they can deal with their every-day problems. Nevertheless, neurotic aptitude means that a subject hasn’’t got
enough skills to manage the every-day life problems, and that he/she shows, facing his/her difficulties, anxiety, panic or
anger. Specifically, the neurotic self doesn’’t see the possibility of action, he/she feels he/she can’’t do anything to face the
problem, also when he/she can. He/she can’’t use any agency. Henry Ey, one of the most studied psychologists in Cuba,
wrote that the neurotic self can’’t adapt him/her-self to the cultural system where he/she lives. He/she expresses the lack
of dasein (being), and he/she becomes a weakened self (Ey, 1978).
So, in the case of the neurotic-self, the psychotherapist should bring back the patients into a healthy social life, should
help them to find their lost agency. When we talk about Cuba, a Socialist Republic where the State is deeply involved in
the daily life of citizens, it could appear that the psychiatric care is a form of governmentality (Foucault, 1977). However
the ethnography suggested to me that this does not appear to be the case, in fact observing psychotherapy and care
practices, it’’s possible to find some ““asymmetries””, some points where the ““Apparatus" [dispositif in French], ““a wider
sense of techniques and procedures designed to direct the behaviour of men””(Foucault, 1977), doesn’’t work.
The clashing of Cuba and the capitalist world economy has heralded a new beginning in Cuba’’s revolutionary
historiography, and has increased these apparatus un-working points. In fact, at first the collapse of the Soviet Bloc, and
most recently the changing of president, from Fidel Castro to his brother Raul, have brought about a change in the Cuban
policy. The dollar has become pre-eminent in an economy in which the average person is paid in Cuban pesos; the new
acts promulgated by Raul Castro could actually become the foundations of the small and medium enterprise for the first
time after the Triunfo de la Revolución (Brotherton, 2009). Anyway, these changes haven’’t come associated, for example,
with a pay increase, or with increasing personal rights (like, for example, the right to leave the country when one wants
to), and for this reason they have produced many doubts about the future of socialism in the island. A Cuban economist,
Aldo Leiba, speaking about it, defined the present time in Cuba as an era of ““shifting ideology”” (Leiva, 2007), it means
that the core values of society are changing with the economic ones. These considerations brought me to analyze the
patients of the Mental Health Community Centre like people who live a double doubt. One linked with the personal issues,
and another one linked with the country issues.
As the results of my ethnographic research suggest, psychiatrists and psychologists don’’t use their role to shape the
psychiatric care into a form of governmentality, they aren’’t only instruments of these procedures, and instead they
assume a critic position in the system, underlining the bond between the neurotic self and a common citizen who lives in
a lack of agency for social and political conditions.
I stress the fact the lack of emphasis of Western Psychiatric categories drives the Cuban psychiatric and psychological
language to bridle common-life vocabulary and to break ““therapeutic frame”” in order to analyze citizens’’ every-day
Moreover, Lakoff wrote that the psychology and psychiatry sciences seem to reside precisely in the border ““between
the ethical question of how one should live and the technical question of how to sustain life”” (Lakoff, 2005, p.14). But we
could say that it is difficult to mark the boundary line between ““the ethical question of how one should live”” and ““the
political and social order that determine how one should live””. The Cuban therapy seems to raise these questions: ““How
should we live in the Cuban State today?”” (for the patients) , and for psychotherapists: ““how can we help a citizen?””.
The Cuban psychotherapeutic model states that it is impossible to cure a human being by separating him or her from
the society he or she lives in. This model puts the person at the core of the system, and considers the curing-process as
systemic and group-process based. By the way, the Cuban psychiatrists consider the person in his/her political dimension
and put the relationship between the State and the citizen at the core of the cure-process.
Then, the use of irony is not expressing a political influence but rather it is acting as a type of social review that points
out the daily challenges each citizen has to face. The patient’’s suffering is located along side the personal challenges
each citizen faces. In this way, it is evident that irony as a psychotherapeutic intervention helps make citizenship an
object of care.
In conclusion, when the therapists break the therapeutic-frame to introduce political and social elements, they do both:
help the people living with the system contradictions and underline the system contradiction, in this sense they are
dealing with the patients’’ double doubt. Introducing the ironic speech, the psychotherapists could be critic without be
reactionary, and could contribute to shape a new critical citizenship. In this way they make a distance between the State
““subjugation””, kept on by the ““apparatus”” where they operate as doctors, and the ““becoming subject”” of the patients,
which in the therapeutic encounter can share (and become mindful of) their private difficulties and public ones determined
by citizen-status.
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